Presentation on theme: "TRACHEOSTOMY CARE Rosie Ratcliffe (Previous Macmillan Head and Neck Clinical Nurse Specialist) Amended 2012."— Presentation transcript:
1 TRACHEOSTOMY CARERosie Ratcliffe (Previous Macmillan Head and Neck Clinical Nurse Specialist)Amended 2012
2 AimsTo provide basis awareness of caring for patients with tracheostomy tubesTo understand the safety implications when dealing with tracheostomiesTo understand complications and emergency procedures with tracheostomy tubes
3 What is a Tracheostomy?A tracheostomy is a surgical procedure that is usually performed under a GA or LA (tracheotomy). It is an incision into the trachea (windpipe) that forms a temporary or permanent opening called a stomaA tube is inserted through the opening to facilitate breathing, protection from aspiration in cases of swallowing impairment and facilitate clearance of secretionsDescribe difference with a laryngectomy – e.g. Laryngeal cancer or deficit in swallow or laryngeal function in neurological disease. Separates lungs and trachea from mouth.
4 Reasons for a Tracheostomy Airway obstruction e.g. Upper airway tumoursLower airways toiletNeurological disease e.g. MNDVocal Cord ParalysisLaryngeal injury or spasmsSevere neck / mouth injuriesAirway burns from inhalation smoke/steamAnaphylaxis
5 Types of Tracheostomy Tubes Double lumen tubes – consist of inner and outer tubes to aid clearance of secretions without changing the complete tube. Tracoetwist, Tracoecomfort, ShilleysFenestrated tubes – these are double lumen with holes built into the shaft to allow air to flow through the vocal cords to facilitate speakingBoth these tubes come either non-cuffed or cuffedCuffed tubes - low pressure air filled cuff at the distal end of the tube allows sealing of the airway used to prevent aspiration and facilitate ventilation
6 Cuffed tubesSeal the airway to facilitate the delivery of positive ventilationPrevent airflow through larynxProtect the airwayPrevent risk of aspirationExternal pilot balloons which indicate when the cuff is inflated or deflatedThe cuff may impair swallowing due to pressure on the oesophagus
7 Un-cuffed tubes Maintain airway patency Do not protect from aspiration Enable voice around the tubeMay be used to weanUsed for long term tracheostomy patientsNot commonly seen in the acute setting
8 Cuff pressures Cuff pressure should be maintained between 15 – 22mmHg Check pressure by using manometers – every shift, minimum of twice in 24 hoursMinimal occlusion pressures / minimal leak texhnique (auscultation around suprasternal notch) not recommended due to risk of silent aspirationVoiceSyringe
9 Common complicationsTracheostomy complications are usually divided into 3 categoriesIntra-operativeEarly post-operativeLate post-operative
12 Late post-operativeGranuloma (growth of inflammatory tissue caused by irritation)Tracheal stenosis (abnormal narrowing of trachea e.g. from tracheal tumour)Tracheomalacia (flaccidity of tracheal cartilage causing tracheal collapse e.g. from fistula)Trachoesophageal fistulaMucosal ulceration
13 Main life-threatening complications and their management - Bleeding Bleeding – this is the most common complication of a tracheostomy. It may occur early or late.Minor- settles with conservative managementMajor- requiring blood transfusion, surgical exploration / other interventionManagement depends on the context in which the bleeding occursPalliative management: Dark green towels, crisis medication, psychological support, suction, external pressure to bleeding site, communication to patient / family debated. Priority - STAY WITH PATIENTActive treatment-Don’t panicCall for help ( Senior H & N Surgeon)Reassure patientBleeding may temporarily be reduced by applying finger pressure to the root of the neck in the sternal notch.If cuffed tube in situ inflate cuff.Await senior medical assistance for urgent intervention.Let theatre know.
14 Tube blockageTracheostomy tubes can become blocked with thick tracheal secretions, blood or foreign bodies. Presentation may be increasing respiratory distress over a few hours or more rapid deteriorationThis can be LIFE THREATENING if not rapidly resolvedPrevention - adequate humidification, regular inner tube changes, suctionDon’t panicCall for help ( Senior Medical / Nursing Staff / Other AHP’s / Physio.Reassure the patientAssess patency of airway / breathing.If patient breathing spontaneously and co-operative encourage to give vigorous cough- this may relive the obstruction.Remove inner cannula and replace with a clean one.If blockage still present attempt tracheal suction this may relieve the obstructionThe full tracheostomy tube may need removing ideally by competent practitioners, but may be neccassary in life threatening situation , when above have not worked.
15 Displaced trachesotomy tubes Tubes can become displaced through a loose or inadequately positioned neck tape, excessive movement of the patient, patient agitation or pulling of equipment that is attached to the tracheostomy tube. A dislodged tube is more dangerous than a completely removed tube Prevention - regular checks of neck tape, ensure equipment is attached safely, manage agitation, regular observation of patient.Don’t panicCall for help ( Senior H & N reg or above )Reassure the patientIf tube is partially dislodged check tube patency the patient may still be able to breathe through it with difficulty.Remove inner cannula to increase tube airway capacity.Check oxygen sat administer oxygen if necessarySenior medical staff may re insert a new tube.If the tube is completely removed within 72 hrs , tracheal dilators may be used to keep stoma open. If tube is completely removed after 72 hrs administer oxygen and await senior medical intervention for tube re insertion.
16 SuctioningSuctioning can be both uncomfortable and distressing for the patient, therefore where possible patients should be encouraged to expectorate their own secretionsPatients individual needs need to be assessed frequentlyIndications for suctioning - unable to expectorate, blockage in tracheostomy tube
17 Suctioning Complications HypoxiaBradycardiaTracheal mucosal damageBleedingInfectionCheck patient sats, consider hyperoxygenation. Can make deterioration quicker in COPDChange suction tubing / walled suction collection bottle at least every 2 hoursSterile water bottle (date and discard and replace at least every 24 hours)Position patient as upright as possible with head in neutral alignmentAlways suction with non fenestrated inner tubeSuction unit mmHg / 13-16kPa (ICS, 2008) to minimise risk of atelectasis collapsed lung tissueInsert tubing no more than a 1/3 of catheter advancedSuction for no longer than 10 secondsCatheter size = (Trachy size -2) x 2e.g. Size 8 trachy would be size 12Fg suction catheterCheck O2 satsSuction can make pt cough, this is ok
18 Types of humidification Heat and Moisture Exchanger (HME)Thermovent –T, Inter-surgical HME common in acute settingsTrachi-naze filters, Buchanan bibs common in long term settingsWater humidifiers - Fischer-Paykel (heated)Respiflow (cool)Saline nebulisersTrachi-sprayLong term water humidification can increase risk of respiratory infections and make the stoma wet / sore.
19 NORMAL MECHANISM OF HUMIDIFICATION Temp 37°C, Rel. Humidity 100% 5cm below carinaCiliated Epithelial CellsMany hair-like structures on each cellbeat within an aqueous layerAqueous LayerLow viscosity fluid- cilia protrude upwards through the aqueous layer on forward stroke to engage mucuc. Curling back within the fluid on backwards stroke releasing mucus. Action moves mucus upwards. Depth of layer is critical for effective movementGel LayerFloats on top of aqueous layer to trap contaminants and moved from the airways by cilia. The moisture content of mucus is important as dry mucus cannot be moved
20 Tube changesTracheostomy tubes should be changed every 28 days as per the European Economic Community Directive (1993)The first tube change should be carried out by a medical practitioner with appropriate, advanced airway skillsHealth professionals who have undergone training and confident / competent
21 INDICATIONS FOR CHANGING TRACHEOSTOMY TUBE: Elective:MonthlyAssess stoma/ trachea and granulation tissue at stoma site and / or fenestrationFacilitate weaningSpeech productionPatient comfortEmergencyBlocked tubeMisplaced or displaced tubeCuff failureFaulty tubeAspirationHypoxiaAnxiety/Discomfort
22 Stoma care Review stoma each shift Assess stoma Clean with NaCl and dry carefullyUse barrier cream to protect skinApply trachi dressing under tubeChange neck tapes at least weeklyEnsure neck tapes are secure allow 2 fingers to fit between the tapes and neck
23 CommunicationThe impact of the loss of normal voice following a tracheostomy should not be under estimatedLoss of voice occurs because no air is passing over the vocal cordsCommunication facilitates- expression of feeling, reassurance, patients needs, advice, counselling, social interaction, information giving
24 Alternative methods of Communication Non-verbalLip readingCoded eye blinkingHand gesturesAlphabet board / Picture boradLight writerCuff deflation / fenestrated tubesIntermittent finger occlusionSpeaking valves
26 Teaching patient to live with Tracheostomy Need lots of reassurance and adviceInvolve patient in stoma care from an early stage, changing inner tube frequentlyInvolve SALT with swallowing and speakingShow patient how to clean around stoma and encourage this on a daily basisAdvice re: looking after skin around stoma siteAltered body image
34 Misplacement into pre-tracheal tissues. VoiceTube extending from stomaDe-saturationPallorAbsent or reduced expired airUnable to pass Suction catheterRespiratory distressMisplacement into pre-tracheal tissues.
37 Summary Each shift always check the tracheostomy tube is patent Know what type / size of tube is in placeKnow patients normal observations if appropriateKnow if the cuff is inflated / deflatedKnow emergency proceduresRefer to protocolAlways know the patients resuscitation status